SpecimenSerum (1 mL) collected in a gold-, red-, or red/gray-top tube. Plasma (1 mL) collected in a green-top (heparin) tube is also acceptable. It is important to use the same tube type when serial specimen collections are anticipated for consistency in testing.
|Risk||Conventional Units||SI Units (Conventional Units × 0.0259)|
|Children and adolescents (less than 20 yr)|
|Desirable||Less than 170 mg/dL||Less than 4.4 mmol/L|
|Borderline||170–199 mg/dL||4.4–5.2 mmol/L|
|High||Greater than 200 mg/dL||Greater than 5.2 mmol/L|
|Adults and older adults|
|Desirable||Less than 200 mg/dL||Less than 5.2 mmol/L|
|Borderline||200–239 mg/dL||5.2–6.2 mmol/L|
|High||Greater than 240 mg/dL||Greater than 6.2 mmol/L|
In November 2013 new guidelines for the prevention of cardiovascular disease (CVD) were developed by the American College of Cardiology (ACC) and the American Heart Association (AHA) in conjunction with members of the National Heart, Lung, and Blood Institute’s (NHLBI) ATP IV Expert Panel. The updated, evidence-based guidelines redefine the condition of concern as atherosclerotic cardiovascular disease (ASCVD) and expand ASCVD to include CVD, stroke, and peripheral artery disease. Some of the important highlights include the following:
- Movement away from the use of LDL cholesterol targets in determining treatment with statins. Recommendations that focus on selecting (a) the patients who fall into four groups most likely to benefit from statin therapy, and (b) the level of statin intensity most likely to affect or reduce development of ASCVD.
- Development of a new 10-yr risk assessment tool id based on findings from a large, diverse population. Evidence-based risk factors include age, sex, ethnicity, total cholesterol, HDLC, blood pressure, blood-pressure treatment status, diabetes, and current use of tobacco products.
- Recommendations for aspects of lifestyle that would encourage prevention of ASCVD include adherence to a Mediterranean or DASH (Dietary Approaches to Stop Hypertension) style diet; dietary restriction of saturated fats, trans fats, sugar, and sodium; and regular participation in aerobic exercise. The guidelines contain reductions in body mass index (BMI) cutoffs for men and women designed to promote discussions between health-care providers (HCPs) and their patients regarding the benefits of maintaining a healthy weight.
- Recognition that additional biological markers, such as family history, high-sensitivity C-reactive protein, ankle-brachial index (ABI), and coronary artery calcium (CAC) score, may be selectively used with the assessment tool to assist in predicting and evaluating risk.
- Recognition that other biomarkers such as apolipoprotein B, eGFR, creatinine, lipoprotein (a) or Lp(a), and microalbumin warrant further study and may be considered for inclusion in future guidelines.
This procedure is contraindicated for
- Assist in determining risk of cardiovascular disease
- Assist in the diagnosis of nephrotic syndrome, hepatic disease, pancreatitis, and thyroid disorders
- Evaluate the response to dietary and drug therapy for hypercholesterolemia
- Investigate hypercholesterolemia in light of family history of cardiovascular disease
Although the exact pathophysiology is unknown, cholesterol is required for many functions at the cellular and organ level. Elevations of cholesterol are associated with conditions caused by an inherited defect in lipoprotein metabolism, liver disease, kidney disease, or a disorder of the endocrine system.
- Acute intermittent porphyria
- Anorexia nervosa
- Chronic renal failure
- Diabetes (with poor control)
- Diets high in cholesterol and fats
- Familial hyperlipoproteinemia
- Glycogen storage disease (von Gierke’s disease)
- Hypothyroidism (primary)
- Ischemic heart disease
- Nephrotic syndrome
- Pancreatic and prostatic malignancy
- Syndrome X (metabolic syndrome)
- Werner’s syndrome
- Although the exact pathophysiology is unknown, cholesterol is required for many functions at the cellular and organ level. Decreases in cholesterol levels are associated with conditions caused by malnutrition, malabsorption, liver disease, and sudden increased utilization. Burns Chronic myelocytic leukemia Chronic obstructive pulmonary disease Hyperthyroidism Liver disease (severe) Malabsorption and malnutrition syndromes Myeloma Pernicious anemia Polycythemia vera Severe illness Sideroblastic anemias Tangier disease Thalassemia Waldenström’s macroglobulinemia
- Drugs that may increase cholesterol levels include amiodarone, androgens, β-blockers, calcitriol, cortisone, cyclosporine, danazol, diclofenac, disulfiram, fluoxymesterone, glucogenic corticosteroids, ibuprofen, isotretinoin, levodopa, mepazine, methyclothiazide, miconazole (owing to castor oil vehicle, not the drug), nafarelin, nandrolone, some oral contraceptives, oxymetholone, phenobarbital, phenothiazine, prochlorperazine, sotalol, thiabendazole, thiouracil, tretinoin, and trifluoperazine.
- Drugs that may decrease cholesterol levels include acebutolol, amiloride, aminosalicylic acid, androsterone, ascorbic acid, asparaginase, atenolol, atorvastatin, beclobrate, bezafibrate, carbutamide, cerivastatin, cholestyramine, ciprofibrate, clofibrate, clonidine, colestipol, dextrothyroxine, doxazosin, enalapril, estrogens, fenfluramine, fenofibrate, fluvastatin, gemfibrozil, haloperidol, hormone replacement therapy, hydralazine, hydrochlorothiazide, interferon, isoniazid, kanamycin, ketoconazole, lincomycin, lisinopril, lovastatin, metformin, nafenopin, nandrolone, neomycin, niacin, nicotinic acid, nifedipine, oxandrolone, paromomycin, pravastatin, probucol, simvastatin, tamoxifen, terazosin, thyroxine, trazodone, triiodothyronine, ursodiol, valproic acid, and verapamil.
- Ingestion of alcohol 12 to 24 hr before the test can falsely elevate results.
- Ingestion of drugs that alter cholesterol levels within 12 hr of the test may give a false impression of cholesterol levels, unless the test is done to evaluate such effects.
- Positioning can affect results; lower levels are obtained if the specimen is from a patient who has been supine for 20 min.
- Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.
Nursing Implications and Procedure
Potential nursing problems
|Problem||Signs & Symptoms||Interventions|
|Pain (Related to myocardial ischemia; myocardial infarction; pericarditis; coronary vasospasm; ventricular hypertrophy; embolism; epicardial artery inflammation)||Reports of chest pain, new onset of angina, shortness of breath, pallor, weakness, diaphoresis, palpitations, nausea, vomiting, epigastric pain or discomfort, increased blood pressure, increased heart rate||Assess pain characteristics, squeezing pressure, location in substernal back, neck, or jaw; assess pain duration and onset (minimal exertion, sleep, or rest); identify pain modalities that have relieved pain in the past; monitor cardiac biomarkers (CK-MB, troponin, myoglobin); collaborate with ancillary departments to complete ordered echocardiography, exercise stress testing, pharmacological stress testing; administer prescribed pain medication; monitor and trend vital signs; administer prescribed oxygen; administer prescribed anticoagulants, antiplatelets, beta blockers, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, Angiotensin II Receptor Blockers (ARBs), thrombolytic agents|
|Cardiac output (Related to increased preload; increased afterload; impaired cardiac contractility; cardiac muscle disease; altered cardiac conduction)||Decreased peripheral pulses; decreased urinary output; cool, clammy skin; tachypnea; dyspnea; edema; altered level of consciousness; abnormal heart sounds; crackles in lungs; decreased activity tolerance; weight gain; fatigue; hypoxia||Assess peripheral pulses and capillary refill; monitor blood pressure and check for orthostatic changes; assess respiratory rate, breath sounds, and orthopnea; assess skin color and temperature; assess level of consciousness; monitor urinary output; use pulse oximetry to monitor oxygenation; monitor sodium and potassium levels; monitor B-type natriuretic peptide (BNP) levels; administer ordered (ACE) inhibitors, beta blockers, diuretics, aldosterone antagonists, and vasodilators; provide oxygen administration|
|Health management (Related to failure to regulate diet; lack of exercise; alcohol use; smoking)||Inability or failure to recognize or process information toward improving health and preventing illness with associated mental and physical effects||Encourage regular participation in weight-bearing exercise; assess diet, smoking, and alcohol use; teach the importance of adequate calcium intake with diet and supplements; refer to smoking cessation and alcohol treatment programs; collaborate with HCP for bone density evaluation|
|Nutrition (Related to excess caloric intake with large amounts of dietary sodium and fat; cultural lifestyle; overeating associated with anxiety, depression, compulsive disorder; genetics; inadequate or unhealthy food resources)||Observable obesity; high-fat or sodium food selections; high BMI; high consumption of ethnic foods; sedentary lifestyle; dietary religious beliefs and food selections; binge eating; diet high in refined sugar; repetitive dieting and failure||Discuss ideal body weight and the purpose and relationship between ideal weight and caloric intake to support cardiac health; review ways to decrease intake of saturated fats and increase intake of polyunsaturated fats; discuss limiting cholesterol intake to less than 300 mg per day; discuss limiting the intake of refined processed sugar; teach limiting sodium intake to the HCP’s recommended restriction; encourage intake of fresh fruits and vegetables, unprocessed carbohydrates, poultry, and grains|
- Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
- Patient Teaching: Inform the patient this test can assist with evaluation of cholesterol level.
- Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex.
- Obtain a history of the patient’s cardiovascular, gastrointestinal, and hepatobiliary systems, as well as results of previously performed laboratory tests and diagnostic and surgical procedures. The presence of other risk factors, such as family history of heart disease, smoking, obesity, diet, lack of physical activity, hypertension, diabetes, previous myocardial infarction, and previous vascular disease, should be investigated.
- Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
- Review the procedure with the patient. Inform the patient that specimen collection takes approximately 5 to 10 min. Address concerns about pain and explain that there may be some discomfort during the venipuncture.
- Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
- Instruct the patient to withhold alcohol and drugs known to alter cholesterol levels for 12 to 24 hr before specimen collection, at the direction of the health-care provider (HCP).
- Note that there are no fluid or medication restrictions unless by medical direction.
- Instruct the patient to fast 6 to 12 hr before specimen collection; fasting is required if triglyceride measurements are included and recommended if cholesterol levels alone are measured for screening. Protocols may vary among facilities.
- Potential complications: N/A
- Ensure that the patient has complied with dietary restrictions and pretesting preparations; ensure that food has been restricted for at least 6 to 12 hr prior to the procedure if triglycerides are to be measured.
- Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
- Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement.
- Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection. Perform a venipuncture.
- Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage.
- Promptly transport the specimen to the laboratory for processing and analysis.
- Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
- Instruct the patient to resume usual diet as directed by the HCP.
- Secondary causes for increased cholesterol levels should be ruled out before therapy to decrease levels is initiated by use of drugs.
- Nutritional Considerations: Increases in total cholesterol levels may be associated with CAD. Nutritional therapy is recommended for the patient identified to be at risk for developing coronary artery disease (CAD) or for individuals who have specific risk factors and/or existing medical conditions (e.g., elevated LDL cholesterol levels, other lipid disorders, insulin-dependent diabetes, insulin resistance, or metabolic syndrome). Other changeable risk factors warranting patient education include strategies to encourage patients, especially those who are overweight and with high blood pressure, to safely decrease sodium intake, achieve a normal weight, ensure regular participation of moderate aerobic physical activity three to four times per week, eliminate tobacco use, and adhere to a heart-healthy diet. If triglycerides also are elevated, the patient should be advised to eliminate or reduce alcohol. The 2013 Guideline on Lifestyle Management to Reduce Cardiovascular Risk published by the American College of Cardiology (ACC) and the American Heart Association (AHA) in conjunction with the National Heart, Lung, and Blood Institute (NHLBI) recommends a “Mediterranean”-style diet rather than a low-fat diet. The new guideline emphasizes inclusion of vegetables, whole grains, fruits, low-fat dairy, nuts, legumes, and nontropical vegetable oils (e.g., olive, canola, peanut, sunflower, flaxseed) along with fish and lean poultry. A similar dietary pattern known as the Dietary Approaches to Stop Hypertension (DASH) diet makes additional recommendations for the reduction of dietary sodium. Both dietary styles emphasize a reduction in consumption of red meats, which are high in saturated fats and cholesterol, and other foods containing sugar, saturated fats, trans fats, and sodium.
- Social and Cultural Considerations: Numerous studies point to the prevalence of excess body weight in American children and adolescents. Experts estimate that obesity is present in 25% of the population ages 6 to 11 yr. The medical, social, and emotional consequences of excess body weight are significant. Special attention should be given to instructing the child and caregiver regarding health risks and weight-control education.
- Recognize anxiety related to test results, and be supportive of fear of shortened life expectancy.
- Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.
- Discuss the implications of abnormal test results on the patient’s lifestyle.
- Provide teaching and information regarding the clinical implications of the test results, as appropriate.
- Educate the patient regarding access to counseling services.
- Provide contact information, if desired, for the AHA (www.americanheart.org) or the NHLBI (www.nhlbi.nih.gov).
- Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP.
- Answer any questions or address any concerns voiced by the patient or family.
- Explain to the patient and the family the anatomy and pathophysiology of the heart and coronary arteries.
- Explain to the patient and the family the risk factors for coronary artery disease.
Expected Patient Outcomes
- Differentiates between the signs and symptoms of myocardial infarction and angina
- Describes the signs and symptoms of heart attack
- Demonstrates readiness to learn and identified their learning preferences
- Demonstrates making food selections that are low in saturated fats and high in polyunsaturated fats
- Displays an emotional response to the cardiac event that is appropriate to the circumstances
- Complies with recommended lifestyle alterations and involvement in cardiac rehabilitation
- Related tests include antiarrhythmic drugs, apolipoprotein A and B, AST, ANP, blood gases, BNP, calcium, cholesterol (HDL and LDL), CT cardiac scoring, CRP, CK and isoenzymes, echocardiography, glucose, glycated hemoglobin, Holter monitor, homocysteine, ketones, LDH and isoenzymes, lipoprotein electrophoresis, MRI chest, magnesium, MI scan, myocardial perfusion heart scan, myoglobin, PET heart, potassium, triglycerides, and troponin.
- Refer to the Cardiovascular, Gastrointestinal, and Hepatobiliary systems tables at the end of the book for related tests by body system.